Basic Information
| Provider Information | |||||||||
| NPI: | 1124060439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIMINO | ||||||||
| FirstName: | KENDRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CORRIVEAU | ||||||||
| OtherFirstName: | KENDRA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LICSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10 ORMS ST | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029042228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014530666 | ||||||||
| FaxNumber: | 4014539619 | ||||||||
| Practice Location | |||||||||
| Address1: | 1524 ATWOOD AVE | ||||||||
| Address2: | SUITE 213 | ||||||||
| City: | JOHNSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029193228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013510400 | ||||||||
| FaxNumber: | 4013510410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | ISW01430 | RI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 29289-6 | 01 | RI | BLUE SHIELD PROVIDER # | OTHER | 412739 | 01 | RI | BLUE CHIP PROVIDER # | OTHER |